J O'Rourke:Proceed 19th Natl TB & Chest Dis Workers Conf, New Delhi, 1964, 195 208 & Indian J TB 1965, 12, 87-94

Control of tuberculosis may be defined as a deliberate interference in the relationship between man and bacillus that changes favourably the epidemiological trend. Compared with the other factors at play on this relationship, the weapons available for a control programme are narrow in their range and must be used with great foresight if they are to benefit the country. Under Indian conditions, with tuberculosis ubiquitous in its occurrence, with no striking focality of infection and disease that would justify selective restricted efforts, control measures must necessarily cover the whole community and the programme must be maintained for a long time. Control will be a slow process, demanding continued investment of men and supplies, persistent and careful organisation. There is no short cut.

The assessment of programme (performance) requires similar approach. Evaluation (impact) must concern itself initially with examining the operational and technical performance, enquiring in detail how the immediate achievement has compared with the forecast, as changes in prevalence are expensive to detect and may not be due to control measures applied. In general, supervision asks if a rule is obeyed: assessment enquires whether it has really been obeyed, whether it can and should be obeyed and whether there might be a better rule. For e.g. evaluation of BCG campaign encompasses the whole series of activities undertaken and not only confined to occasional surveys of post-vaccination allergy. It is important for curative work also. Pilot evaluation report of Anantapur programme after one year in 1962 is given as an example of simple assessment. A great majority of patients diagnosed at district centre came from outside, while at peripheral hospitals 90% came from the same taluk. Treatment completion were 38% to 40% among patients belonging to the same town and very low among those living outside. This gives importance of Case-finding in peripheral centres. Referral also played very little part. The accuracy of diagnosis, proportion of cases diagnosed, number completed treatment and rendered negative, are included in the assessment. Besides these, cost of the programme and expansion of the programme to the whole district, accuracy of the case index, operational achievements at individual centre/district, prevalence of initial drug resistance among clinic patients, should also be considered. Even such an elementary evaluation demands careful organization and clear procedures: staff must be allotted and trained for the purpose and equipment must be provided. The assessment must be objective and independent: it seems appropriate that the procedures would be undertaken, in each state, by staff from the State Tuberculosis Centre, Regional Offices under the Union Government could also be involved. The responsible centres must have portable, hand operated punching equipment and facilities for sputum culture. If tuberculosis in India is to be controlled by human intervention and health to be effectively promoted, independent assessment of programmes, feeding back into research so that problems will be solved and the solutions timely applied, is absolutely essential. As yet, both methodology and the organisation needed are embryonic and demand therefore particular attention and priority. Administrators and scientists alike face, in nurturing evaluation, an unusually difficult and promising challenge. Recognising and accepting a challenge is in itself an important development.